Worth the Investment: Supporting Families Early for Future Success

Early childhood development and subsequent adult health outcomes are influenced by the relational environments in which children grow, learn, and play. A child who is living in an environment with positive, nurturing, and supportive relationships and consistent routines is more likely to develop well-functioning neurodevelopmental and biological systems, including brain circuits, that promote positive development and lifelong health.1 The American Academy of Pediatrics’ clinical report on trauma-informed care promotes a relational-health framework including promoting positive parenting skills and safe, stable nurturing relationships and environments.2 An emerging theme from the available literature is that investing in early relational health (ERH) yields returns for children, families, and communities across generations.3In this issue of Pediatrics, Miller et al describe an integrated primary care–based program that explores the impact of evidence-based parenting interventions and early childhood development through implementation of Smart Beginnings (SB), a tiered birth-to-3 positive parenting model designed to improve school readiness in children from low-income households. SB integrates 2 evidence-based interventions—a universal primary prevention strategy (PlayReadVIP) in the pediatric primary care home and a targeted prevention strategy Family Check-Up (FCU), a home-based family-centered intervention.4The pediatric primary care home and a child’s home environment are optimal settings for universal health care–based interventions in the earliest years. Evaluations of evidence-based programs such as HealthySteps, which partner early childhood developmental specialists with pediatricians to promote early social emotional development and improve family well-being, demonstrate that children in this program are more likely to receive recommended preventive and developmental services and families demonstrated enhanced ERH.5 Home visiting is a cornerstone of developmental support for families in the birth-to-3 period with a strong but at times mixed evidence base.6,7 As a result of large-scale federal investments in home visiting since 2010, home visiting services and evaluation research have expanded substantially across the United States over the past 15 years. Some researchers have advocated for a more universalized approach to home visiting as a pathway to greater equity and program reach.8 Programs combining point-of-care screening and intervention with in-home follow-up in the early years are rare and offer an interesting learning opportunity by the alignment between universal screening and follow-up on targeted home-visiting services for families identified as those who could benefit most.This study examined the effects of the early childhood SB parenting model on children’s later academic skills at age 6 as part of a single-blind, 2-site randomized clinical trial (RCT). The findings were significant in that they demonstrated that nurturing the parent-child relationship in early childhood has a positive influence on children’s development later in life, including academic outcomes and school readiness. Of particular relevance to pediatric care is that the SB model promotes school readiness by incorporating elements of ERH, motivational interviewing, positive parenting, and early childhood developmental skill building.9The study’s rigorous design, using a tiered, integrated care model with a racially diverse patient population, yielded significant findings for future parenting interventions. It provides compelling evidence that an early clinical approach with a universal supportive parenting intervention and strong focus on parental cognitive stimulation, combined with a targeted home-visiting component for families with known additional risks, can reduce disparities in future school readiness.The SB model’s focus on tailoring content to caregivers’ individual strengths and needs reflects an important trend in home visiting and related early childhood fields, as model developers are heeding the call for customizable approaches vs a one-size-fits all curriculum. Although still within an overarching framework of fidelity, precision home visiting and caregiver-led approaches use screening surveys and parent-practitioner conversations to identify and prioritize appropriate visit content.10 The SB model not only includes an upstream ERH intervention but also introduces a mental health clinical practice lens (FCU) to this tailoring process, in which master’s-level clinicians leverage their field’s ecological assessment and collaborative dialogue approaches to client-centered practice to inform FCU curriculum delivery.The intervention was limited to families with relatively stable circumstances: parents of single, full-term infants without developmental challenges, who had medical insurance, a regular physician, and stable housing. Families experiencing more significant stressors—such as homelessness, chronic instability, or lack of access to consistent medical care—were not represented yet may derive substantial benefit from such interventions.Positive outcomes in the study required participation in a combination of 2 distinct interventions (PlayReadVIP and FCU), with not all families completing both. Additionally, both models are delivered by professionals with advanced degrees, and the combined intervention was delivered in a large urban setting where early childhood workforce issues may be less prevalent than in rural communities. This raises questions about feasibility and scalability in real-world practice. Future work might explore whether variations of hybrid models that integrate the strengths of both interventions can be designed and effectively implemented at scale across different communities.Although the study highlights the racial and cultural diversity of participants, it does not examine whether tailoring interventions to specific cultural communities could improve engagement and retention. Evidence-based programs, such as ParentCorps, assert that honoring caregivers’ culture is an essential element to building adult capacity to support young children’s health and development.11 Additionally, fit to the Tribal Maternal Infant and Early Childhood Home Visiting context12 and other indigenous home visiting settings often excluded from early-stage research should be addressed in subsequent studies. Native American and Pacific Islander home visiting programs have been leaders in approaches to tailoring at the individual and community levels of implementation. Indigenous communities have unique health care system considerations, and Native Americans have a larger rural population distribution than others in the United States.12A major part of the intervention was delivered primarily in pediatric offices. Although pediatricians are trusted practitioners, some families may experience skepticism or mistrust of medical institutions.13 Implementation in other community-based settings—such as community centers, family resource centers, faith-based organizations, or through doulas and other trusted community leaders—may increase accessibility, cultural relevance, and sustainability, especially if the trained staff and the community members have a shared experience. Additionally, examining the impact of racial and cultural concordance between practitioners and families may yield important insights. Lastly, expanding the participants of the study to include fathers, grandparents, and other caretakers offers an opportunity for relationship building and strengthening connections beyond the traditional dyad.Early investment in evidence-based ERH practices can yield high returns in the form of school readiness, academic achievement, and improved long-term health. A public health approach to promote ERH—with integrated interventions such as SB—encourages pediatric health care practitioners, researchers, early childhood caretakers and educators, and family serving groups to engage at multiple levels of a child’s ecosystem.14 The intentional collaboration of ERH-promoting activities across family serving sectors offers opportunities for building the relational capacities of all of the adults in the lives of young children to support their future health, well-being, and educational success.Thank you to Dr David Willis for his review of the manuscript.